Article ID: WMC001830 2046-1690 Induced Abortion on Demand (IAD) in Norway 1979-2009 and a Pre IAD Comparator. A Markov Model Based Cost-Effectiveness Analysis (CEA) Corresponding Author: Prof. Jan Norum, MD, PhD, North Norway Regional Health Authority trust, N-8038 - Norway Submitting Author: Prof. Jan Norum, MD, PhD, North Norway Regional Health Authority trust, N-8038 - Norway Article ID: WMC001830 Article Type: Original Articles Submitted on:31-Mar-2011, 10:34:05 PM GMT Published on: 01-Apr-2011, 05:33:10 PM GMT Article URL: http://www.webmedcentral.com/article_view/1830 Subject Categories:ECONOMICS OF MEDICINE Keywords:Induced Abortion, Norway, Health Economics, Markov Model How to cite the article:Norum J . Induced Abortion on Demand (IAD) in Norway 1979-2009 and a Pre IAD Comparator. A Markov Model Based Cost-Effectiveness Analysis (CEA) . WebmedCentral ECONOMICS OF MEDICINE 2011;2(4):WMC001830 Source(s) of Funding: North Norway Regional Health Authority trust Competing Interests: None WebmedCentral > Original Articles Page 1 of 13 WMC001830 Downloaded from http://www.webmedcentral.com on 24-Dec-2011, 04:34:59 AM Induced Abortion on Demand (IAD) in Norway 1979-2009 and a Pre IAD Comparator. A Markov Model Based Cost-Effectiveness Analysis (CEA) Author(s): Norum J Abstract campaigns in the junior high school and high school to educate young Norwegians on the use of contraceptives, the annual abortion figures have been constant. At present every fifth known pregnancy in Objective: In the western world, there is a growing Norway is terminated by induced abortion (1). The concern about an aging population. The number of corresponding figures in Denmark, Sweden and births per women has been low for decades. The England have been reported 1/6, 1/4, 1/5, respectively objective was to clarify the cost-effectiveness with (2). Similar figures (22 per 100 pregnancies) has been regard to induced abortion on demand (IAD) and a reported from the United States (3-4). comparator. During the last years, Norwegian health care Methods: A Markov model was established, time administrators and politicians have expressed a perspective was 31 years (1979-2009) and two growing concern on how to meet the challenges of an alternatives compared. A) The induced abortion on aging population and an increasing dropout from the demand (IAD) as performed. B) A comparator where workforce due to disability. During the last three 2/3rds of the IAD were avoided to obtain pre IAD decades, low birth figures have altered the figures. Health care (C1), patient/family (C2) and other composition of the European population. In the future sectors (C3) costs together with production losses (C4) less young people will have to take care of an were calculated in both arms. Savings (S) in terms of increasing number of elderly people. To handle this life years gained (LYG), health care (S1), upcoming situation, three national reforms have been patient/family (S2) and other sectors (S3) savings launched in Norway; A pension reform encouraging together with production gains (PG) (S4) were Norwegians to stay in the workforce until the age of 70 included and based on data from Statistics Norway. A years, a national insurance reform aiming at less 4% discount rate (d.r.) was used. people being reported ill and finally a coordination Results: Between 1979 and 2009, a total of 452,112 reform where more patient care is taken care of in the pregnancies were terminated. In the comparator arm, primary health care, aiming to save economic 301,408 additional births were obtained and further resources and preserve quality of care (5). In a new 5,772 births were added as the children grew up. LYG trend with a strong need for a healthy young was indicated 2,372,699 (4% d.r.). Based on the generation who can stay in the workforce and take model, the cost/LYG (4% d.r., all resource use) was a care of the growing number of elderly, it is of interest saving of Euro 74. Excluding family costs/savings, the to compare this development with the induced abortion figure was Euro 5,187 saved/LYG. The major cost on demand in Norway during the last three decades. factors were family related costs (66%) and costs in In this study the cost effectiveness was focused and other sectors (23%). Health related costs were any ethical aspects were not concerned. negligible (2.5 %). The major saving was due to PG. Conclusion: From a societal perspective, an Methods intervention avoiding induced abortions is very cost effective and welfare services counteracting family costs are important. Health economic model Introduction A Markov model was established and three states were implemented (Figure 1). The cost effectiveness analysis was performed from the societal point of view. State A representing a foetus aged 12 weeks or less, Induced abortion on demand (IAD) has been state B included a normal birth, state C death or implemented in most western countries during the last terminated pregnancy. Arrows show how the decades. Since 1979, women in Norway have had the foetus/child progress through the model over the right to have an IAD performed. Despite the cycles, which were taken to be 1 year. The transition introduction of new contraceptives and several WebmedCentral > Original Articles Page 2 of 13 WMC001830 Downloaded from http://www.webmedcentral.com on 24-Dec-2011, 04:34:59 AM probabilities were according to data from Statistics Costs Norway (1). The time perspective was 31 years, which All costs were calculated according to Norwegian unit was the time period of the act on demand abortion in costs and converted into Euros at the rate of 1 Euro = Norway (1979-2009). The total cost included health 7.782 NOK as of March 10th 2011 care costs (C1), patient/family costs (C2), costs in (www.norges-bank.no). other sectors (C3) and productivity losses (C4). The Costs may be divided into health care costs, costs economic benefits were correspondingly in terms of related to patient/family, costs in other sectors and health care savings (S1), patient/family savings (S2), productivity losses (6).The health care costs with savings in other sectors (S3) and productivity gains regard to induced abortion on demand and the (S4). The economic benefits were in terms of health alternative of birth is mainly related to hospitalisation, care savings (S1) (6). out-patient follow up of complications. Costs related to Various assumptions can be made in a patient/family are the shares paid for out-patient visits. cost-effectiveness analysis (CEA) depending on which In the comparator arm there will be significant costs costs and economic consequences that are account (kindergarten, food, clothes, transportation etc.) with edfor. A narrow analysis accounts for health care regard to taking care of a growing child. Costs in other costs and consequences only, i.e. C1 - S1. A broad sectors are societal costs with regard to kindergarten analysis include indirect costs and production gains and education and finally productivity effects as the (PG) as well, something that provides an estimation of grown ups enter the work force. net social costs, i.e. C1+C2+C3+C4-S1-S2-S3-S4. In The Markov Model was run from time of pregnancy to a CEA, costs are compared with the incremental death or end of study period (Figure 1). A time health gain; E2-E1 as measured in life years gained perspective of 31 years and the life expectancy of (LYG). The exact resource consequence of avoiding Norwegians according to Statistics Norway was abortion is not known. However, modelling can offer employed (1). Most authors employ discount rates support to decision makers as long as it reflects between 3 and 5%. A 4% discount rate was employed real-world alternatives (7). in the study and 0% and 5% was included in the Treatment, comparator and effectiveness. sensitivity analysis. The discount rate was based on The Norwegian act on demand abortion stipulates that the guide and recommendation from the Ministry of any woman aged 18 years and above has a right to Finance (8). pregnancy termination in a public hospital at no cost to Health care costs (C1) her and without stating any reasons. The terms A) Abortion. The health care costs (C1) were include she is a resident of Norway and the calculated according to the Diagnosis Related Groups interruption is performed before the end of 12th week (DRG) system and the price list as of January 2011 (9) of gestation. Since 1979, the annual abortion rates (DRG 1.0 = Euro 4,750). The cost of an induced have been stable around 15.000 cases. Details are abortion was based on DRG 381O (Euro 556). shown in Figure 2. In this model, the comparator was B) Comparator. There were 9 suggested follow ups a suggested strategy where the pregnant women were during pregnancy and one follow up afterwards (10). supported and informed that the society is in great They were at 7-10th week, 18th week (incl. ultrasound need for children and therefore will prepare for and exam DRG 914Q = Euro 152) and at 24th, 28th, 32th, welcome the baby. A 67% success rate was employed 36th, 38th, 40th and 41 th weeks of pregnancy and with a sensitivity analysis ranging from 33 to 100%. one follow up after delivery. The cost of each visit to The success rate was based on the gap from the the General Practitioner (GP) was for the first visit present fertility figure (1.9) per woman and the mean Euro 44.5 and for the others Euro 38. The cost of fertility rate (2.1) the last nine years prior to the giving birth was based on DRG 373 (Euro 2,185).